Health policy and planning最新文献

Financial protection is a core pillar of universal health coverage (UHC), yet current monitoring approaches in low- and middle-income countries (LMICs) largely focus on direct medical costs, neglecting direct transport costs and indirect time costs lost when seeking care. This commentary highlights the importance of fully accounting for these often-excluded costs, which disproportionately affect poorer and rural populations and can significantly hinder access to essential health services and lead to foregone care. We outline five priority areas for action, including improved measurement of transport and time costs through household surveys, methodological advancements in valuing time, increased investment in primary health care to reduce physical access barriers, adaptation of financing schemes and social protection programs to cover non-medical costs, and a multisectoral approach to address structural determinants. Fully integrating these dimensions into financial protection metrics and policies is critical for ensuring more equitable progress toward UHC in LMICs.

Most sub-Saharan Africa (SSA) countries are implementing free maternity services starting from the first antenatal care (ANC) visit to postnatal care. However, out of pocket (OOP) health expenditures significantly affect the utilization of maternal services in SSA. Limited evidence exists on the costs incurred for ANC health service utilization in this region. This study aimed to assess the costs of ANC service utilization among adolescent and adult women in Eastern Ethiopia. Data were collected from pregnant women participating in the Kersa Health and Demographic Surveillance Site (KHDSS). The study prospectively followed 394 pregnant women across two rounds, collecting both direct medical and indirect costs of ANC service utilization. Direct medical and non-medical costs were summed up to give OOP health expenditures. Catastrophic health expenditure (CHE) and intensity were assessed using the budget share approach at different thresholds. All costs were converted to 2023/2024 USD and compared between adolescent and adult women. A total of 390 women were included in the final analysis. The total amount of OOP payment due to ANC service utilization was 35.7 USD among adolescents compared to 28.5 USD in adults. Adolescents spent 32.6 USD on direct medical costs compared to 24.9 USD for adult women, and 19.3 USD on direct non-medical costs compared to 19.8 USD in adult women. There was a significant difference in the proportion of women who incurred OOP payments, 85.7% of adolescents versus 66.7% of adults (P-value < .001). CHE incidence among adolescents was 46.8% and 15.6% compared to 28.7% and 9.3% among adult women at 5% and 15% threshold, respectively. Overall, adolescent women faced higher financial hardship than adult women. This highlights the need to expand financial protection beyond direct medical costs and to develop targeted financial protection mechanisms specifically for adolescents in resource-limited settings. Furthermore, strengthening the implementation and ensuring the sustainability of the Free Maternal Services policy could help reduce disparities in service utilization between adolescent and adult women.

In the absence of documented health workforce deployment policies and limited access to key job history data, existing health systems research methods are inadequate for examining policy implementation. The analysis of self-reported job histories offers a valuable research method for overcoming these limitations; however, its application and usefulness remain largely unexamined in health system and policy research, particularly in the context of health workforce and policy implementation. In this paper, we reflect on our experiences of using self-reported job histories to investigate the experiences of public sector doctors with deployment systems related to recruitment, initial posting, and transfers. We interviewed 33 public sector doctors from two Indian states to gain insight into their experiences with policies and systems related to deployment. The initial interview process revealed a pattern in which the doctors developed a work-life chronology to organize their responses. This was formalized in subsequent interviews, creating structured chronological job histories. Job histories serve as a useful and flexible research method for understanding the complexities of how health workforce deployment systems operate and are experienced by health workers. Commentary by doctors regarding these job histories revealed negative perceptions of transfer practice, disruptions in their career trajectories, and gaps in policy implementation. The recollection process of forming job histories is organic and fluid, rich in qualitative data, and its construction involves making sense of diverse work-related stories of health workers. Job histories offer flexibility for collecting data in a more structured manner through a simple set of quantitative questions. Despite their usefulness, constraints such as the inability to triangulate and recall bias exist. Beyond research, job history analysis has practical implications; it is useful for policy implementers and researchers through a more nuanced analysis of challenges related to effective workforce management systems, thereby improving workforce planning, policies, and systems.

Current approaches to health system resilience tend to prioritize system-level outcomes (e.g. functionality) while overlooking key underlying social processes, contexts, and power-laden interactions through which resilience is produced. When community resilience is subsumed under health system resilience, without attending to distinct contextual factors, it can lead to fragmented approaches or maladaptive outcomes that misalign with the resilience of communities. Therefore, resilience approaches need to include additional methods that incorporate analyses of power structures and context. We propose intersectionality theory as a methodological lens to investigate the underlying social processes and power dynamics that shape community resilience and health system resilience interactions. An intersectionality approach prompts researchers to distinguish how resilience capacity is derived through the involvement of community actors, their unique intersecting social identities and their lived experiences. Including an intersectional lens in resilience approaches provides researchers with the tools to identify points of practical constraints that arise at the intersection of communities and health systems, with particular attention on the burdens that are placed on community actors.

In rural Indigenous communities in the Peruvian Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Peru has a large cadre of Community health workers (CHW), yet their potential is not harnessed. A recent outcome evaluation of a community-based intervention showed improvements in essential newborn care (ENC) for home births and small increases in facility births. To explain these findings, elucidate the pathways of change, and derive policy recommendations, we conducted a mixed-methods process evaluation. Implementation strength, mechanisms of change, and influence of contextual factors were assessed using data collected from women, CHW, traditional birth attendants (TBA), supervisors, and community members. We calculated programme coverage and intervention exposure and explored experiences, perceptions, and birth stories through interviews, focus group discussions, and participant observation using content analysis. Triangulated findings were narratively synthesized and contrasted to hypothesized intervention mechanisms. The programme achieved high coverage of well-trained CHW and TBA supported by intensive supervision. Multiple pathways of change were identified: Trained TBA as main providers of home-based birth care implementing ENC; CHW home visits sensitizing women through educational videos and provision of delivery kits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to facility care, while promotion alone to increase demand appeared insufficient. Pathways of change identified support a causal link between the intervention and observed behaviour changes in the outcome evaluation. Our findings demonstrate the potential of community-based approaches involving CHW and TBA which should be given greater importance in national health policy. To improve impact and sustainability of the Peruvian CHW programme, we provide several context-specific recommendations.

Primary healthcare provider networks (PHCPNs) are increasingly recognized as promising strategies to effectively strengthen health systems in low- and middle-income countries (LMICs). However, there is limited information on the influence PHCPNs may have on the process and clinical outcomes of health services. This study sought to answer the questions: what is the extent, range and nature of research on PHCPNs in LMICs, what are the types of PHCPNs described, and what are the processes e.g. access to care, coverage of health services, quality of care and services, safety of care and the clinical care outcomes of PHCPNs reported in the published literature? We report on a systematic mixed-methods review on PHCPNs as a strategy to strengthen health systems in LMICs following the PRISMA guidelines. The quality of the included studies was assessed using the ROBINS-I and Mixed Methods Appraisal tools, while a narrative synthesis was employed to describe the results. Fifteen primary studies were found eligible for the review. From the included papers, eight types of PHCPNs were identified across various contexts and countries. We found that the PHCPNs primarily focus on maternal, newborn, and child health outcomes. The study reveals that: (1) PHCPNs contribute to improvements in the process outcomes of health services by enhancing access to care, coverage of health services, quality of care and services, and safety of care, and (2) they support improvements in clinical outcomes by helping to reduce maternal, neonatal, and perinatal mortalities and stillbirths. This body of literature we reviewed suggests that PHCPNs make a difference in the process and clinical outcomes of health services in LMICs. This review serves as both a mapping and clarification exercise to promote the adoption of PHCPNs and as a foundation for further research, especially in areas of health services beyond maternal, newborn, and child health.

India's second wave of the COVID-19 pandemic in April-June 2021 involved an explosion of case numbers, with devastating consequences for the country's already strained health systems. This case study examines the private health market response to the pandemic in Uttar Pradesh, India's most populous state. We analyzed 203 news articles to understand both the experiences of private providers and patients in response to government policies being implemented in the state. This analysis informed our interviews with 20 state-level officials, district-level key informants, and formal and informal private-for-profit providers across 3 districts. We found that private sector hospitals were rapidly engaged to manage a surge in new infections and severe cases, but private bed capacity quickly filled, causing patients to be turned away. Informal private providers played a vital role in rural areas, serving as round-the-clock care sources. However, the news media reported inadequate medical care from such providers leading to COVID-19-related deaths. Access to reliable information on COVID-19 was challenging and social media became a platform for citizens and providers to share information about available resources, treatment, and COVID-19 management. However, misinformation also spread. While the government attempted to counter misinformation and regulate private hospitals, challenges persisted in providing and accessing accurate information. Oxygen and drug supply challenges also emerged, with private hospitals requiring patients to arrange oxygen due to scarcity. To address this and rising costs of care, the government issued price caps, monitored overcharging, and regulated drug and oxygen distribution. Government schemes also attempted to provide insurance for both public and private health workers, however, awareness and implementation of such schemes were inadequate. Policymakers should develop mechanisms to engage, or where relevant, integrate all private-for profit providers onto a common platform, strengthen referral linkages amongst them, and support communities of practice to increase awareness of government health policies and improve the implementation of government schemes. All together, these measures would help facilitate equitable access to care and help manage current health needs and future health emergencies.

Community pharmacies are increasingly recognised as access points for public health interventions (PHIs) such as vaccination, family planning services and disease screening. In Kenya, evidence suggests feasibility of pharmacy delivered PHIs, however, the uptake remains inconsistent. This is partly attributed to poor program design without taking pharmacy providers preferences into consideration. We employed a discrete choice experiment (DCE) to investigate community pharmacists preferences for attributes of PHIs delivered in community pharmacies in Kenya. We constructed a Bayesian efficient design and conducted a DCE survey among 663 community pharmacy providers in Makueni, Nairobi and Kisumu counties in Kenya from January 2025 to March 2025. Panel multinomial mixed logit, generalised multinomial logit and latent class models were used in the analysis. We also estimated willingness to pay (WTP) and willingness to accept (WTA) estimates using cost and profit margins as the monetary estimates respectively. We found that community pharmacists were willing to offer PHIs with a low preference for opting out (β=-3.5723, P<0.01). Preferences for PHIs significantly increased with higher profit margins (β=0.028, P<0.01) and decreased with higher cost of equipment (β= -0.00023, P<0.01). There were higher preferences for PHIs that require moderate training (β=0.266, P<0.01) and extensive training (β=0.141, P<0.05) compared to no additional training; and lower preferences for PHIs with complex interventions compared to simple interventions (β=-0.323, P<0.01). The WTP estimates showed that providers were willing to pay Khs. 11,738 (USD 90) for moderate training and Kshs. 7,327 (USD 56) for extensive training. Moreover, the WTA estimates showed that providers were willing to accept a 10.9% increase in profit margin in order to deliver complex interventions. In addition to this, a three-class latent class model revealed preference heterogeneity among the respondents. These findings can be used to inform the design of PHIs to enhance uptake and acceptability among providers.

Implementing evidence-based alcohol policies can reduce the negative impact of alcohol consumption on public health. However, Brazil has permissive alcohol policies and weakly adheres to World Health Organization's recommendations as the 'best buys'. To explore stakeholders' perceptions of alcohol policy needs and barriers in Brazil, we conducted semi-structured interviews with 31 stakeholders, including 15 from civil society and 16 policymakers. Civil society participants included non-governmental organization leaders addressing alcohol-related issues, while policymakers comprised civil servants and politicians experienced in alcohol-related harms. Interviews were transcribed verbatim and thematically analyzed using a deductive approach guided by research questions and an inductive approach to identify emergent themes. Most participants supported World Health Organization-recommended 'best buy' policies regulating alcohol's marketing. However, agreement on price and availability control was not unanimous. All participants acknowledged significant political barriers to adopting these policies, including intentional delays in parliamentary voting, industry lobbying, and arguments about infringing on rights such as freedom. Facing obstacles to advancing population-level policies, stakeholders often shifted their focus to individual-level interventions, such as education and treatment. While these were recognized as less effective, educational efforts were highlighted for raising public awareness of alcohol's harms and changing normative beliefs. Participants noted the lack of a formal coalition to reduce alcohol-related harm, despite its perceived necessity. Overall, stakeholders supported population-level alcohol policies but were pessimistic about their implementation due to political barriers. Many, particularly from civil society, emphasized small-scale, targeted interventions as a more feasible alternative to address alcohol-related harm in Brazil.